Value of ST‐segment change in lead aVR in diagnosing left main disease in Non‐ST‐elevation acute coronary syndrome—A meta‐analysis

Abstract

Non-ST-elevation acute coronary syndrome (NSTE ACS) includes unstable angina pectoris and non-ST-elevation myocardial infarction. The patient with NSTE ACS has a variable severity and prognosis. Early stratification of the patient is very important in reducing the incidence of sudden death and adverse events. The electrocardiogram (ECG) is a rapid and noninvasive diagnostic method, which exerts a critical role in the assessment of early risk stratification. Left main coronary artery (LMCA) is one of the major factors that affect the patient's prognosis. Atie found that most patients with LMCA lesions would appear to have ST-segment elevation (STE) in lead V1 and aVR and ST-segment depression in lead V3, V4, and V5 (especially in lead V4) when chest pain occurs (Atie et al., 1991).Lead aVR is often ignored in clinical practice. However, a number of studies have shown that the STE in lead aVR had a great significance on the prediction of vascular anticipation and clinical prognosis in patients with acute myocardial infarction (Nair & Glancy, 2002;Yamaji et al., 2001). As the research advanced, researchers commonly thought that STE in lead aVR suggested severe left main lesion or serious multivessel lesions (Li et al., 2009). But the results were not consistent among different stud-

A Systematic Approach to Evaluate Patients Presenting With ST-Segment Elevation in Lead aVR: A Case Series

“…Since lead aVR reflects the myocardial perfusion of the basal septum, which is often affected by the LMCA or ostial/proximal LAD, it has gained significance in detecting acute myocardial ischemia. Due to the high mortality rates of these lesions, there has been an extensive examination of applying STE in aVR as a diagnostic and prognostic tool for these high-risk lesions [ 5 - 7 ]. The addition of diffuse ST-segment depressions in eight or more leads to the STE in aVR was found to have a predictive accuracy of 75% for LMCA or triple vessel disease [ 5 , 8 ].…”

“…The addition of diffuse ST-segment depressions in eight or more leads to the STE in aVR was found to have a predictive accuracy of 75% for LMCA or triple vessel disease [ 5 , 8 ]. The degree of STE (>0.5 mm vs <0.5 mm) in lead aVR was associated with significantly different predictive values for left main or multi-vessel CAD in patients with the acute coronary syndrome (ACS), specifically STE > 0.5 mm in lead aVR significantly predicted high risk of having LMCA or multi-vessel CAD in a recent meta-analysis [ 7 ]. Knotts et al reported a 43% rate of coronary angiography (57 patients) as part of the evaluation for patients who presented to the ED with ECG findings of STE in lead aVR and ST-segment depressions in over seven leads [ 9 ].…”

Electrocardiographic signs of the left main coronary artery disease in acute coronary syndrome

“…Отведение aVR обеспечивает информацию об электрической активности базальной части межжелудочковой перегородки (МЖП). Окклюзия СтЛКА или проксимального сегмента ПНА приводит к трансмуральной ишемии базальной части МЖП с направлением вектора повреждения во фронтальной плоскости вверх, что ведет к элевации ST в aVR [6,10,21,26,31,[34][35][36]. Однако базальная часть МЖП имеет двойное кровоснабжение из первой септальной ветви ПНА и правой конусной артерии, которая часто берет начало из правой коронарной артерии (ПКА) или прямо от правого коронарного синуса.…”

“…Следует отметить, что элевация ST в aVR может также наблюдаться при тромбоэмболии легочной артерии, диссекции аорты, критическом аортальном стенозе, миокардите, синдромах Бругада, такоцубо, отравлении трициклическими антидепрессантами, при блокаде левой ножки пучка Гиса, гипертрофии ЛЖ [6,31,32,38]. Данный ЭКГ-признак необходимо оценивать совместно с изменениями в других отведениях и клиническими данными [6,38].…”

“…Частота поражения СтЛКА при ОКС, по различным данным, составляет от 5% до 12% [6][7][8]. Это зависит от того, в какой группе проводилась оценка -при инфаркте миокарда (ИМ) с подъемом ST (ИМпST), ИМ без стойкого подъема ST (ИМбпST), была ли это окклюзия или стеноз СтЛКА.…”